Principles of Coding & Reimbursement

Principles of Coding & Reimbursement Presented by Harry Goldsmith, DPM Workshop ehandouts www.codingline.com Workshop ehandouts www.codingline.com 1

Workshop ehandouts www.codingline.com Disclaimer Not everything I say is true My Goal Is to Get You to Here 2

I ve Got Some Bad News CPT 76880 was deleted. Instead CPT introduced CPT 76881 and CPT 76882 Unfortunately, CMS valued CPT 76882 at 0.89 RVUs And You Want to Get Paid, Too? There are only two ways medical practices or clinics get paid: Insurance (3 rd Party) Cash (Patient) Insurance Reimbursement You agree to follow their rules You are reimbursement dependent In the struggle between value and cost cost tends to win 3

Diagnosis Inflammation of the Blue Cross YOU BE THE JUDGE Surgery: Matrixectomy with subungual exostectomy, right hallux 4

Procedures: CPT 11730 (nail avulsion) CPT 28124 (exostectomy dist phal) HCPCS A4550 (sterile tray) Services: CPT 99218 (initial observation) CPT 93790 (BP monitoring) CPT 95955 99 (EEG) CPT 90788 (IM injection antibiotic) CPT 64450 (peripheral nerve block) CPT 64450 (peripheral nerve block #2) CPT 20500 (inject sinus tract) Procedures: CPT 28126 (condylectomy dist phal) CPT 11762 (reconstruction nail bed/graft CPT 11765 (wedge resection skin) CPT 11755 (biopsy nail unit) CPT 11755 (biopsy nail unit #2) CPT 11740 (evacuation hematoma) CPT 11760 (repair nail bed) 5

Procedures: CPT 14000 (adjac tissue transf, trunk) CPT 15740 (flap, island pedicle) CPT G0168 (wound closure adhesive) Services: CPT 99373 (telephone call, complex) CPT 88300 26 (path, gross prof) CPT 88300 TC (path, gross TC) SO, WHAT WAS THE TOTAL BILLED FOR THE SURGERY? $1,452.00? nope $6,112.00? nope $13,480.00 6

Other Billings: CPT 99204 CPT 99275 (confirmatory consult. compr) CPT 99218 (initial observation) CPT 99214 CPT 99373 x 3 post op HCPCS G0168 (adhesive closure) x3 CPT 15852 (dressing change anesth.) CPT 13160 (secondary closure, dehiscence, extensive) Where Were We? Oh, Yeah, Insurance Reimbursement You agree to follow their rules You are reimbursement dependent In the struggle between value and cost cost tends to win 7

Cash Money You set your real fees Patients take more responsibility in their role as consumers You don t have to bill a 3 rd party payer; you don t have to wait for payment You hardly ever get audited (except by the IRS) In the struggle between value and cost value tends to win Cash is Good Back to Reality 8

Basics of Reimbursement Most patients we see are covered by some form of health insurance These plans can vary in coverage from patient to patient The fact is the plans can vary within the same insurance company Insurance Coverage Depends Cheap plans may only cover basic services, emergency procedures, some elective procedures Some employer provider plans can include just about everything while others not so much Plans can specifically exclude services Example: deny palliative services, orthopedic shoes and foot orthotics Some plans direct doctors to refer to contracted ancillary services Reimbursement Is Based On 1) Being a plan benefit service, procedure, or item 2) Being a standard of care g 3) Meeting medical necessity 9

Medical Necessity Matching the intensity of the service to the seriousness of the illness no more, no less than necessary to be medically beneficial for the patient Medical Necessity Medically necessary care should be expected to reasonably improve long term patient symptoms and function 10

Reimbursement: What, Why, How, & Why Again Reimbursement Resources The Centers for Medicare & Medicaid Services (CMS) Local/regional non Medicare payers American Podiatric i Medical Association i American Medical Association Private sources: Codingline Reimbursement Resources The Centers for Medicare & Medicaid Services (CMS) Local/regional non Medicare payers i di i di l i i American Podiatric Medical Association American Medical Association Private sources: Codingline 11

CMS Medicare https://www.cms.gov/mlnproducts/downloads/physicianguide.pdf TrailBlazer Medicare http://www.trailblazerhealth.com/medicare.aspx Reimbursement Resources 12

DME Medicare If you participate, you become a supplier (physician) You have to separately enroll You have wholly different responsibilities i as a supplier than you do as a physician 13

DME Medicare There are 4 DMACs (DME Medicare Administrative Contractors) NHIC Jurisdiction A NGS Jurisdiction B CIGNA Jurisdiction C Noridian Jurisdiction D Jurisdiction C DMAC Virginia Jurisdiction C DMAC LCDs 14

Jurisdiction C DMAC LCDs Jurisdiction C DMAC Virginia Reimbursement Resources 15

Reimbursement Resources The Centers for Medicare & Medicaid Services (CMS) Local/regional non Medicare payers American Podiatric i Medical Association i American Medical Association Private sources: Codingline Non Medicare Payers Non Medicare Payers 16

Non Medicare Payers Non Medicare Payers 17

Reimbursement Resources The Centers for Medicare & Medicaid Services (CMS) Local/regional non Medicare payers i di i di l i i American Podiatric Medical Association American Medical Association Private sources: Codingline 18

APMA Reimbursement Resources APMA member website (www.apma.org) APMA Coding Resource Center 19

APMA Reimbursement Resources Private Insurance Resource Guide Global Surgical Services Report BMAD(Part B Medicare Annual Data) References Private Insurance Company Complaint Form Primer on Silent PPOs APMA Reimbursement Resources DME Primer DME fact sheet regarding accreditation and surety bonds How to info on e Prescribing and PQRS Info on NCCI, NPI, COPs Links to key Medicare Web sites Specific insurance company policies and much more APMA Reimbursement Resources APMA member website APMA Coding Resource Center 20

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Reimbursement Resources The Centers for Medicare & Medicaid Services (CMS) Local/regional non Medicare payers American Podiatric i Medical Association i American Medical Association Private sources: Codingline American Medical Association Reimbursement Resources The Centers for Medicare & Medicaid Services (CMS) Local/regional non Medicare payers i di i di l i i American Podiatric Medical Association American Medical Association Private sources: Codingline 24

Other Reimbursement Resources Codingline Disclaimer: I am the CEO of Codingline Codingline is not an APMA product Codingline Codingline 25

Codingline Codingline It s free for APMA members www.codingline.com/apmasilver.htm com/apmasilver Coding Guidelines 26

Within the CPT Surgical guidelines E/M guidelines Service/procedure guidelines Global Surgical Guidelines What s in, what s out? Global Surgical Guidelines What s in, what s out? Local anesthetic injections in Dressing changes in Follow up visits in Related minor procedures e.g., I&D of suture abscess mostly in Related pain management in Initial cast, splint, strapping at surgery in 27

Global Surgical Guidelines What s in, what s out? Decision for surgery out (well, mostly) Subsequent cast, splint, strapping applications out Casting supplies out Return to the operating room out Unrelated care/surgery out DME out E/M Services Guidelines https://www.cms.gov/mlnproducts/downloads/eval_mgmt_s erv_guide ICN006764.pdf 28

Guidelines Within CPT ICD 9 GUIDELINES http://www.cdc.gov/nchs/data/icd9/icdguide10.pdf Documentation 29

Handwritten Fill In Combo 30

Macro; Template E/M Coding History of Present Illness E/M Coding: Past Medical History Family History 31

E/M Coding Review of Systems E/M Coding: Physical Exam General E/M Coding: Ingrown Nail Exam 32

Imaging Studies E/M Coding Assessment E/M Coding: Medical Decision Making 33

E/M Coding: Medical Decision Making Just Touching on Modifiers COMMON MODIFIERS 24 25 26 57 58 51 59 78 79 80 22 52 TA thru T9 LT RT 34

ICD 9 CM International Classification of Diseases, 9 th Revision, Clinical Modifications ICD 9 CM ICD 9 coding should be used to develop a more precise clinical picture of the patient for third party reporting 35

ICD 9 CM Coding Must be accurate Must be specific Do not code rule outs t Code to the highest level ICD 9 CM Codes: Diseases Conditions Complaints Signs Symptoms Circumstance ICD 9 CM Samples 798.1 drop dead E836.2 employee injury from a washer/drier (laundry room) on board a ship 36

ICD 9 CM Samples E844.8 sucked into a jet without damage to airplane; ground crew E846.9 injury in a theater ICD 9 CM Samples E912 bean in nose E300.23 fear of washing in public ICD 9 CM Samples E923.8 E906.8 569.42 injury from torpedo pecked by a bird pain in the ass 37

And What About ICD 10? ICD 10 CM October 1, 2013 3+ years to get ready ICD 10 CM ICD 9 codes are numeric characters 3 5 in length; there are about 13,000 codes ICD 10 codes are alphanumeric 3 7 characters in length; there are about 68,000 codes 38

ICD 9 CM ICD 10 CM Category - Etiology/Anatomic Site/Severity Extension ICD 9 CM ICD 9 729.5 pain in limb ICD 10 CM R52.0 acute pain R52.1 chronic intractable pain R52.2 other chronic pain R52.9 pain, unspecified Generalized pain NOS M25.5 pain in joint M79.6 pain in limb ICD 9 CM ICD 10 CM V49.71 Lower limb amputation status, great toe Z89.411 Acquired absence of right great toe 39

ICD 10 CM Fracture codes require a 7 th character The fracture extensions are: A - Initial encounter for closed fracture B - Initial encounter for open fracture D - Subsequent encounter for fracture with routine healing G - Subsequent encounter for fracture with delayed healing K - Subsequent encounter for fracture with nonunion P - Subsequent encounter for fracture with malunion S - Sequelae A Mix of Surgical Coding 40

Excision of Benign & Malignant Lesions CPT 11420 11426 (benign) CPT 11620 11626 (malignant) 0.2 cm each 2 cm 2 cm + 0.2 cm + 0.2 cm = 2.4 cm 41

Laceration Repairs Simple Repair superficial (involving skin and superficial subq) Intermediate Repair layered repair (involving skin, deeper subq, and superficial fascia) Complex Repair more than layered closure debridement, scar revision, retention sutures, etc. Laceration Repairs CPT 12001 CPT 12007: Simple repair of superficial wounds of the extremities (including feet) CPT 12031 CPT 12037: Repair, intermediate, wounds of extremities CPT 12041 CPT 12047: Repair, intermediate, wounds of feet Laceration Repairs CPT 13120 CPT 13122: Repair, complex, legs CPT 13131 CPT 13133: Repair, complex, feet 42

And Laceration Repairs CPT 12020: Treatment of superficial wound dehiscence; simple closure CPT 12021: Treatment of superficial wound dehiscence; with packing CPT 13160: Secondary closure of surgical wound or dehiscence, extensive or complicated And How Do You Code Laceration Repairs? Document, document, document Measure the length of each laceration Record each laceration repair as in the simple, intermediate, or complex group Add the sum of each laceration within each group to give you a single length for all the lacerations in that group Now look up the code representing that group Laceration Jubilee Blue Simple Repair 1) 1.1 cm 2) 2.3 cm TOTAL: 3.4 CM Red Intermediate Repair 1) 4.7 cm 2) 2.8 cm 3) 5.1 cm TOTAL: 12.6 CM Yellow Complex Repair 1) 7.4 TOTAL: 7.4 CM 43

Laceration Jubilee Blue Simple Repair TOTAL: 3.4 CM CPT 12002 Red Intermediate Repair TOTAL: 12.6 CM CPT 12045 Yellow Complex Repair TOTAL: 7.4 CM CPT 13132 I&D of Paronychia If I resect a portion of nail to treat a paronychia, can I bill CPT 10060? Well To bill CPT 10060, you ve got to have an abscess (collection of pus) CPT 10060 vs. CPT 10061 Exactly how do you define a complicated toe abscess? 44

CPT 11765 Wedge excision of skin of nail fold (e.g., for ingrown toenail) What is it, really? CPT 11765 Wedge excision of skin of nail fold (e.g., for ingrown toenail) DeVries, Surgery of the Foot, 2 nd Edition, 1965 45

Bunions & Hallux Valgus oh my Doctor, I Can t Understand Why My Feet Hurt Sculpture Produced By Molding 46

Hallux Abductovalgus Bunionectomy Codes CPT: Hallux Valgus (Bunion) Correction, hallux valgus (bunion), with or without sesamoidectomy; CPT 28290 simple exostectomy (eg, Silver type procedure) CPT 28292 Keller, McBride, or Mayo type procedure 47

CPT: Hallux Valgus (Bunion) Correction, hallux valgus (bunion), with or without sesamoidectomy; CPT 28293 resection of joint with implant CPT 28294 with tendon transplants (eg, Joplin type procedure) CPT: Hallux Valgus (Bunion) Correction, hallux valgus (bunion), with or without sesamoidectomy; CPT 28296 with metatarsal osteotomy (eg, Mitchell, Chevron, or concentric ti type procedures) CPT 28296 This procedure includes a distal metatarsal osteotomy. AAOS states that this procedure includes: arthrotomy, synovial biopsy, tendon release or transfer, synovectomy, capsular release and reconstruction, removal of additional exostoses in the area of the joint, internal fixation, articular shaving, arthroscopy, removal of bursal tissue, repair of released tendon, implant insertion, local bone graft and allows additional coding and report for: phalangeal osteotomy to correct deformity, harvesting and insertion of bone graft from distant site (separate skin or fascial incision), and ankle tendon lengthening. American Academy of Orthopaedic Surgeons (August 2002 Bulletin) Bunionectomy Coding 48

CPT: Hallux Valgus (Bunion) Correction, hallux valgus (bunion), with or without sesamoidectomy; CPT 28297 Lapidus type procedure CPT 28298 by phalanx osteotomy CPT 28299 by double osteotomy Hallux Varus Coding There is no single code for hallux varus repair. You bill what you did sort of: Metatarsal osteotomy? CPT 28306 Soft tissue release only? CPT 28313 (Reconstruction, angular deformity of toe, soft tissue procedures only) or CPT 28270 Phalangeal osteotomy? CPT 28310 CPT: Hallux Valgus (Bunion) Here s one you don t think about CPT 28760 Arthrodesis, with extensor hallucis longus transfer to first metatarsal tt neck, great toe, interphalangeal joint (eg, Jones type procedure) 49

Bunionectomy Pearls Only one bunionectomy per foot, please There is no code for subchondral drilling Bunionectomy Pearls Fixation is included with exception of external fixator use BUT you d better be prepared to explain the medical necessity and standard of care issues for its use Bunionectomy with TightRope is just a bunionectomy 50

Coding with Implants CPT 28293 for 1 st MPJ implant CPT 28899 (unlisted) for lesser MPJ implant CPT 28285 for inter digital implant CPT 28899 or S2117 for subtalar arthroereisis implant Coding Hammertoe Procedures Hammertoe 51

A Rose By Any Other Name Hammertoe, Mallet Toe, Clawtoe, Cocked Up Toe, Overlapping Toe, Curly Toe What is a toe worth? Hammertoe Coding CPT 28285 CPT 28010 CPT 28270 CPT 28286 CPT 28313 CPT 28285 CPT 28899 52

CPT 28313 Reconstruction, angular deformity of toe, soft tissue procedures only (eg, overlapping second toe, fifth toe, curly toes) No bone of contention 5 th digit correction Hallux varus Abducted or adducted digit at MTPJ Hammertoe Dislocation (at the MPJ) I have a patient with a hammertoe which she says has been present for years. Can I bill the MTPJ release as an open treatment of dislocation? No Future Shock 53

Healthcare Delivery Evolution The number of changes, new regulations, new requirements, new demands by not only Medicare, but state and federal agencies is overwhelming solo practitioners, small groups, even large groups. The question: How will all this impact foot & ankle specialists in the coming years? Healthcare Delivery Evolution Practices will deal with it Practices will ignore it and do business as usual Practitioners ii will look to change roles with ih associates Healthcare Delivery Evolution Some practitioners will retire early Some practitioners will look to get out & get employed Some practitioners ii will look to merge practices Some practitioners will look to any viable arrangements out there to reduce their administrative headaches 54

What We Are Seeing Graduating residents and young practitioners are Not looking to go it alone Looking for larger groups ortho, multispecialty, li podiatric What We Are Seeing Graduating residents and young practitioners are Don t want to deal with administrating a practice Want a salary & benefits and be told which room to go into next Questions? 55